GW1-2023-02524_Well Construction - GW1_20230406

I
WELL CONSTRUCTION RECORD(GW 1) For internal Use Only:
1.Well contractor information
: �
14.i,YATER ZONES
Well Contractor Name FROM1f TO DESCRIPTION
NC Well Contractor Certification Number ft. ft.
�- 15.OUTER CASING for multi-cased wells OR LINER(ifily lleable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. ft. in.
����e�js 16.INNER CASING OR TUBING eothermal closed400 2.Well Construction Permit#:ND_Trgr. FROM TO DIAMIUER
List all applicable)"ell construction permits(i.e.U1C.Cmaul.Slate,Variance,etc.) ff. THICKNESS MATEMAL
ft. la.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
❑Agriculttual ❑Municipal/Public FROM To Dl'i]LfETER SLOT SIZE THICICNLes MATERIAL
ft.
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) IL in.
❑Industrial/Conmiercial ft. ft. to
❑Residential Water Supply(shared)
❑Irri anon 18.GROUT
❑Wells>100,000 GPD FROM To M1IATERIAL EMPLACEMENT METHOD&AMOUiW
Non-Water Supply Well: ft. [t.
❑Monitoring ❑Recovery
Injection Well. ,, [t M
❑Aquifer Recharge t4 6.u-ndwater Remediation ft. ft.
OAquifer Storage and Recovery ❑Salinity Barrier 19,SAND/GRAVEL PACK if upplicalile
'FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage - ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) moM TO DFSCRIPTION m►or,1111rduess,sotUrork ty e, rain siie,etc.
ft, f
4.Date Wells Completed: -`�`1 f�1 23
Well I[D#
C le'
5a.Well Location: mot' l ^� Fr, ft. _
C�.G 1 h('m i L a �wI eJ IV CD 0V G 019-3 7 fr. ft.
Facility/OtvnerName �/ FacilityID#(if applicable) ft. ft.
APR
I l Z D Sfr e P� /�p 11-4e t:f ,y Z&s'J 9' ft. ft. a a
Physical Address,City,and Z,P ft, n+':= i •�n r r,^::�. ,:r. 1�1;;I
L t-D-VeAl 21.REMARKS
County Parcel Identification No.(PiN) na/ 0%�'�S �Y a/✓L f�,Q �, f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LJ/,eC/ V" -vA Wt't(�...f-fd
(if well field,one lat/long is sui icicat)
`'7 22.Certification:
6.is(are)the well(s): ❑Permanent or emporary Signature of Certified Wcii Contractor Date
-'_ Bp signingthisform,1 hereby cergf}�Ilia[the well(s)was(were)constructed in accordance wtrh
7.Is this a repair to an existing well: ❑ 19
Ycs or 90 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Meg Construction Standards and that a copy if this is a repair,fill mrt known hell construction information and explain Nee nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only,I GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:_ .36
24.SUBMITTAL IlVSTRUCTIONS
9.Total well depth below land surface: /S at.)
For multiple wells list all depths if different(example-3@200•and 2@100)For this GW I within 30 days of well completion per the following:
10.Static►eater level below top of casing: 3. 61 ft 24a. For All Wells: Orkinal form to Division of Water Resources (DWR),
If ivater level is above casing,rise •+•• ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 5- (in,) 24b.For Infection Wells:Copy-to DWR,Underground Injection Control(IUC)
p Program,1636 MSC,Raleigh,NC 27699-1636
/�
12.Well construction method: �t r ee r / s
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Su'
aly and Onen-Loop Geothermal Return Wells•Copy to the
county environmental health department of the county where in
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Droducine over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield m Permit Program,1611 MSC,Ralc,gh,NC 27699-
(gP ) Method of test:
1611
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13b.Disinfection type: Amount: -
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018